DESCRIPTIVE ARTICLE

Improvement in Student Performance and Perceptions

through a Flipped Anatomy Classroom: Shifting from Passive
Traditional to Active Blended Learning
1,2
Abir El Sadik, * Waleed Al Abdulmonem3
1
Department of Anatomy and Histology, College of Medicine, Qassim University, Qassim, Kingdom of Saudi Arabia
2
Department of Anatomy and Embryology, College of Medicine, Cairo University, Cairo, Egypt
3
Department of Pathology, College of Medicine, Qassim University, Qassim, Kingdom of Saudi Arabia

One of the major challenges facing anatomy educators is delivering the anatomy materi-
als in fewer hours with a reduction of anatomy courses in the integrated curricula. The
flipped classroom modality may be an innovative solution. However, its effectiveness
remains under debate due to a lack of outcome-based research and the mixed results of
students’ performance. The present study aimed to determine the outcome of the flipped
classroom based upon the level of student cognition. The study investigated performance
on 17 multiple-choice anatomy questions as a part of the final examination of the muscu-
loskeletal system module. The results were compared between the first-year female students
of Qassim Medical College, specifically the flipped classroom group (46 students) of the
academic year (2018–2019) and the traditional group (49 students) of the academic year
(2017–2018). The mean differences in the students’ grades on the anatomy questions at
the level of knowledge, application, and analysis using Cohen’s d test were 0.43, 1.41, and
1.01, respectively. These results suggest the positive impact of flipping the students’ class-
rooms on improving their levels of thinking according to Bloom’s taxonomy. Perception
surveys also revealed students’ enthusiasm for the pre-class activities, leading to a better
performance in the class with more engagement with their peers and teachers. The present
study suggested that the flipped classroom modality can be performed to compensate for
the reduction of anatomy educational hours. However, further studies are recommended to
investigate the best practices of the flipped classroom that fit with the students’ needs and
workloads. Anat Sci Educ 0: 1–9. © 2020 American Association for Anatomy.

Key words: Gross anatomy education; flipped classroom; blended learning; students’
engagement; students’ performance; pre-class; online uploading; Blackboard learning
management system

INTRODUCTION (Khan, 2007; Topping, 2014; Yaqinuddin et al., 2016). In addi-

Recently, many medical schools have opted to reduce the anat-
omy curriculum, partly as a result of the expansion of scientific
knowledge and the introduction of new medical technologies
*Correspondence to: Prof. Abir El Sadik, Department of Anatomy and
Histology, College of Medicine, Qassim University, P.O. Box 6655,
Buraidah 51452, Kingdom of Saudi Arabia. E-mail: abeer.ouaida@
kasralainy.edu.eg
Additional supporting information can be viewed in the online version
of this article.
Received 12 February 2020; Revised 4 August 2020; Accepted
27 August 2020.
Published online ## ### ## in Wiley Online Library (wileyonlinelibrary.
com). DOI 10.1002/ase.2015
© 2020 American Association for Anatomy
tion, the adoption of integrated curricula has led to shrinking of
traditional basic science courses, including the gross anatomy
lectures and cadaveric laboratories (Waterston and Stewart,
2005; Bergman et al., 2011; Kemeir, 2012). However, both clini-
cians and anatomists believe that adequate and precise knowl-
edge of human anatomy is of utmost importance for safe clinical
practice (Dangerfield et al., 2000; Fasel et al., 2005). Given this
alarming situation, anatomy educators have begun to endorse
new educational strategies in which students can actively par-
ticipate and apply the important factual and clinical anatomi-
cal information within the reduced timeframe (Estai and Bunt,
2016; Morton and Colbert-Getz, 2017; Day, 2018; Fleagle et
al., 2018). It has been demonstrated that learning time is much
decreased when promoting students to become more active
participants in their education (Ferrer-Torregrosa et al., 2016).

Anatomical Sciences Education ## 2020 Anat Sci Educ 0:1–9 (2020)

Active, student-centered learning has been documented to be
more effective than passive, teacher-centered traditional lec-
tures, as active learning gives students more opportunities
to problem solve and think critically (Moravec et al., 2010;
Andrews et al., 2011; Pierce and Fox, 2012; Prober and
Heath, 2012; Freeman et al., 2014). Among new pedagogical
approaches, the flipped classroom is an innovative teaching
methods that fosters student engagement (Mazur, 2009; Prober
and Khan, 2013; Moffett and Mill, 2014; Bates et al., 2017;
Kellesarian, 2018; Zheng and Zhang, 2020).
The flipped classroom is an inverted, blended teaching
model where the interaction in the classroom and the home-
work are swapped (McLaughlin et al., 2014; Hurtubise et al.,
2015; Moffett, 2015; O’Flaherty and Philips, 2015; Sharma
et al., 2015; Prasad Kuppili and Venkatachelam, 2017; Hew
and Lo, 2018). The students are asked to read from textbooks
and watch lecture presentations and prerecorded video tuto-
rials as self-directed learning (SDL) before classroom atten-
dance (Prober and Heath, 2012; Critz and Knight, 2013; Roehl
et al., 2013; Bouwmeester et al., 2016; Shin and Brock, 2017;
McLean and Attardi, 2018; Kraut et al., 2019). A keystone that
promotes these pre-class activities is the systematic facilities
provided by modern technologies (Strayer, 2012; Asef-Vazini,
2015; Bakr et al., 2016b; Boeve et al., 2017; Han and Klein,
2019). During classroom sessions, the students are encouraged
to engage with more difficult comprehensive levels and deeper
learning through case studies analysis and problem-solving
exercises (Baeten et al., 2010; Strayer, 2012; Freeman et al.,
2014; Hussey et al., 2014; Kim et al., 2014; Watson, 2015).
One of the benefits of this student-driven learning is provid-
ing the teacher with ample time to recognize the knowledge
gap of the students and their level of understanding (Moravec
et al., 2010; Prober and Khan, 2013; Moraros et al., 2015;
Chen et al., 2017; Roe et al., 2019). After the class, the students
are asked to merge and integrate their knowledge through
extra readings, completion of tasks, and peer-sharing discus-
sion, providing them more flexibility with the deeper learning
process (Abeysekera and Dawson, 2015; Hwang et al., 2015;
Sharma et al., 2015; Ding et al., 2019). Several researchers
have recorded the efficacy of the flipped classroom on students’
performance and perceptions over the traditional lectures in
multiple disciplines, such as anatomy and histology (Topping,
2014; Veeramani et al., 2015; Bakr et al., 2016a; Cheng et al.,
2017; Morton and Colbert-Getz, 2017; Day, 2018; Fleagle
et al., 2018), physiology (Tune et al., 2013; Street et al., 2015;
Gopalan and Klann, 2017; Megaw and Zimanyi, 2019), bio-
chemistry (Ojennus, 2016; Taylor et al., 2017; Williams et al.,
2018), radiology (Belfli et al., 2015; O’Connor et al., 2016),
and emergency medicine (Heitz et al., 2015; Lew, 2016; Kraut
et al., 2019). Moreover, this educational methodology has been
shown to improve learning outcomes in other nonmedical dis-
ciplines including dentistry (Park and Howell, 2015; Bakr et al.,
2016a; Kellesarian, 2018), pharmacy (Pierce and Fox, 2012;
McLaughlin et al., 2014; Koo et al., 2016; Kugler et al., 2019),
nursing (Critz and Knight, 2013; Woodruff et al., 2014; Della
Ratta, 2015; McCutcheon et al., 2015; Betihavas et al., 2016;
Hanson, 2016), physics (Deslaureiers et al., 2011; Cagande and
Jugar, 2018), engineering (Mason et al., 2013; Priyaadharshini
and Sundaram, 2018; Castedo et al., 2019; Lo and Hew, 2019),
and mathematics (Freeman et al., 2014; Grypp and Luebeck,
2015; Sun et al., 2018; Sun and Xie, 2020).
In Saudi Arabia, 40% of medical schools utilize traditional
educational curricula. The other 60% have switched to more
interactive, problem-based curricula (Omar, 2009; Yaqinuddin
2
et al., 2016). The College of Medicine at Qassim University was
the first in Saudi Arabia to introduce the problem-based learn-
ing (PBL) approach as its principal educational strategy since it
was established in 2001 (Alamro and Schofield, 2012; Alamro,
2019). The PBL represents the core educational approach and
covers the objectives of the modules, while the lectures, labora-
tories, and other educational activities are planned to facilitate
students’ understanding of the problems designed in the PBL
sessions (Saqr and Alamro, 2019). The college program lasts for
six years and is divided into three phases. The first phase, the
preparatory year, is considered the premedical year. The second
phase consists of the first, second, and third basic years, which
comprise the integrated modular body systems. The third phase
is clinical, comprising the fourth and fifth years. Each mod-
ule in the first three basic years involves integration between
multiple disciplines (gross anatomy, histology, embryology,
physiology, biochemistry, pathology, pharmacology, health in
the community, and clinical skills) (Alrebish et al., 2020). The
module materials, including the anatomy topics, are delivered
via multiple methods, such as large group lectures which out-
line the broad frame of the subject area. The laboratory ses-
sions for cadaver dissection, prosection, and demonstration on
the plastic and the plastinated specimens follow the lectures,
allowing for more understanding and hands-on practical expe-
rience. The students practice active learning methods through
PBL, team-based learning (TBL), seminars and panel discussion
in small groups (Yaqinuddin et al., 2016). Variable methods are
used for the assessment of students in the three basic years. The
theoretical examination consists of integrated multidisciplinary
questions in the form of multiple-choice questions (MCQs),
modified essay questions (MEQs), and short-answer essay
questions (SEQs). In addition, tutors evaluate the students’ per-
formance in the PBL sessions and seminar presentations. At the
end of each module, an integrated, multidisciplinary, objective
structured practical examination (OSPE) is held for practical
evaluation (Saqr and Alamro, 2019).
The aim of the present study was to explore the effect of the
flipped classroom on students’ performance in anatomy and
perceptions of their educational experience in the female sec-
tion of the College of Medicine at Qassim University, Kingdom
of Saudi Arabia. The flipped classroom is designed to give
the teacher more time and opportunity to assist the students
in applying, analyzing, and evaluating the anatomy materi-
als. Therefore, the assessment of a higher level of cognition in
Bloom’s taxonomy (application and analysis) (Anderson et al.,
2001) is recommended to evaluate the impact of the flipped
classroom.
MATERIALS AND METHODS
Participants and Study Design
Participants were first-year students from the female section
of the College of Medicine, Qassim University in the academic
years 2017 to 2018 (n = 49) and 2018 to 2019 (n = 46) regis-
tered in an integrated module called the musculoskeletal system
(MSK). The MSK module (11 weeks in both academic years)
provided a broad spectrum of the anatomy of different regions
(bones, muscles, and joints), which constituted a considerable
proportion of the body structure and function. The gross anat-
omy discipline in this module was integrated with other disci-
plines such as histology, embryology, physiology, biochemistry,
microbiology, pathology, pharmacology, and community and
clinical skills. The MSK module materials were instructed as
El Sadik and Al Abdulmonem
follows: 31% large group lectures, 41% laboratory sessions,
20% PBL sessions, 3.3% TBL sessions, 1.7% seminar presen-
tations, and 3% panel discussion. The anatomy materials in the
MSK module consisted of 16 hours of large group lectures; all
of them were delivered as traditional lectures in the academic
year (2017–2018), while eight lectures were delivered as flipped
classrooms in the following academic year (2018–2019), with
34 hours of laboratory sessions in both years. The experimen-
tal protocol was approved by the ethical research committee of
the College of Medicine at Qassim University with a reference
number QS 20180840.
A between-subjects design was planned to detect the dif-
ference between students’ performance in the objectives of the
8 hours of the flipped and the traditional classrooms. Results
of the 17 questions concerning the study objectives out of the
35 anatomy MCQs of the final summative examination of the
MSK module, classified according to Bloom’s taxonomy, were
used as the principal study outcome to compare between the
students’ results of the flipped lectures of the academic year
(2018–2019) and those of the traditional lectures of the aca-
demic year (2017–2018).
Flipped and Traditional Anatomy Classrooms
The anatomy objectives of the selected eight lectures (8 hours)
delivered to all 46 students as a flipped classroom in the aca-
demic year (2018–2019) were the same as the eight traditional
lectures (8 hours) delivered to all 49 students in the previous
academic year (2017–2018). The traditional lectures con-
sisted of an explanation of the objectives of each class, with
some oral interactive teacher–students’ questions in between
the instruction. For the eight flipped classrooms, the anat-
omy materials of the pre-class activities were constructed
as video tutorials. PowerPoint® Microsoft Office 365®,
(Microsoft Corp., Redmond, WA) was used to create slides
presentations with animations. Adobe Illustrator©, Creative
Cloud (CC) software, (Adobe Systems Inc., San Jose, CA) and
Adobe Photoshop©, CS software, (Adobe Systems Inc., San
Jose, CA) were used to produce anatomy drawings and illus-
trations created by the anatomy faculty, and were added to
their explanations in the PowerPoint presentations during the
recorded video tutorials using “Record Slideshow.” Twenty-
eight video tutorials (with three to four assigned for pre-class
activity before every lecture) were prepared, averaging 8 min-
utes in length, and covering the basic anatomical theoretical
knowledge to prepare the students before coming to the class.
Instructions about the learning objectives nominated pages
in the required and essential anatomy textbooks, as well as
educational web links of anatomy materials provided in the
Saudi Digital Library (SDL; Ministry of Education, Riyadh,
Kingdom of Saudi Arabia), to be visited and studied before
each flipped class, were added to the video tutorials. These
materials were uploaded on the Blackboard learning manage-
ment system, version 9.1 (Blackboard Inc., Washington, DC),
keeping in consideration a sufficient time for pre-class study,
around 1 week before the class. In-class activities included
large group discussions with an average of eight problem sets
for each lecture. The class was designed to engage the students
through teacher–student interaction and peer-tutoring to stim-
ulate student interest, problem solving, and reasoning skills. A
quiz was developed at the end of each class (posttest), cover-
ing the learning objectives in that period in the form of small
group discussions to encourage every student to participate.
Anatomical Sciences Education ## 20203
The posttest questions included MCQs, fill in the text blank,
and fill in the labeled blank illustrations incorporated in the
video tutorials. Post-class activities included assigned online
interactions with the teacher and peers in the form of open-
ended questions in the discussion board on the Blackboard. All
students were required to share in the discussion. Formative
quizzes in the form of MCQs, matching, extended matching,
and fill in the labeled blank illustrations were uploaded on the
Blackboard to be solved in a requested time. Both the flipped
and traditional classes had the same learning objectives,
duration of classes, and other laboratory activities (cadaver
dissection, prosections, plastic, and plastinated models demon-
strations). Student orientation sessions about flipped class-
rooms were done before conducting the classes to prepare
them for both pre-class study and in-class sharing activities as
well as to clarify expected outcomes. An awareness session for
the anatomy staff about the technique and possible benefits
of the flipped classroom was done to prepare them for future
implementation. Further orientation sessions were requested
and conducted for faculty members of other departments of
the college of medicine to share this active learning method.
Assessment Materials
All first-year students of both academic years finished the
MSK system module final summative MCQs examinations (see
Supporting Information file). All disciplines were assessed in
100 questions with 35 (35%) anatomy questions. The exam-
inations were constructed with a blueprint which determined
the accurate sampling of the content areas. The questions
were constructed by each department sharing in the module,
and then, revised by the module committee and organizer.
Seventeen anatomy questions were postulated based on the
same objectives of the traditional and flipped classrooms
of both years and constructed by the same anatomy profes-
sor to ensure content validity evidence for the examinations
(Cook and Beckman, 2006; Morton and Colbert-Getz, 2017).
Item analysis was performed for both examinations for diffi-
culty and discrimination, and no items were found with poor
discrimination (less than 50% of students). Cohen’s d test
was determined by calculating the mean difference between the
two groups of students, the first one taught through flipping
the anatomy classrooms of the academic year (2018–2019), the
second one taught through a traditional manner in the previous
academic year (2017–2018), and then, dividing by the pooled
standard deviation of the data (Cohen, 1992). It was applied
to compare the strength of the relationship between the two
groups regarding the students’ age and their results in anat-
omy questions at the level of knowledge, applying, and analysis
as well as their total scores in the final examinations of the
MSK system module. These data were subjected to statistical
analysis using Statistical Package for the Social Sciences (SPSS)
software, version 22 (IBM Corp., Armonk, NY). Results were
considered significant when the P-value was less than 0.05.
Two different surveys were designed to collect students’
and teachers’ perceptions of the flipped classroom method
as a new educational strategy. They consisted of five closed-
ended questions using a five-point Likert scale (see Supporting
Information files). The students and staff were asked to rank
their feedback: 1 (strongly disagree), 2 (disagree), 3 (neu-
tral), 4 (agree), and 5 (strongly agree). The responses were
measured as a percentage based on the numbers of stu-
dents and teachers who selected a score of four and above.
vThe students were also requested to write narrative open-
ended comments regarding the flipped classroom experience.
The survey results were collected and reviewed. Cronbach’s
alpha test was used for all items of the students’ and staff
surveys to assess the internal consistency and reliability
(Taber, 2018). The Kendall’s tau B coefficient was used as
a nonparametric measure of the strength and direction of
association existing between two variables and to assess the
validity of the surveys (Abdi, 2007). The average points on
the Likert scale responses for each item were expressed as the
mean ± standard deviation (±SD).
The qualitative, open-ended comments were analyzed by
two independent investigators using open coding, then, cate-
gorized into key concept groups. Each comment was labeled
as related to the following three themes: pre-class resources,
in-class activities, and benefits of the flipped classroom (See
Supporting Information file). Comments were classified as
positive, negative, or bearing suggestions for improvement for
each topic area. A final round of axial coding was implemented
to confirm the collection of all important concepts. In order
to determine the appropriateness of the data to proceed with
factor analysis, reexamination of the validity of the students’
and staff surveys was done through the Kaiser-Meyer-Olkin
Measure (KMO) of sampling adequacy, which indicates the
proportion of variance in variables that might be caused by
underlying factors. Bartlett’s test of sphericity was performed
as an indicator of the strength of the relationship among vari-
ables (Chan and Idris, 2017).
RESULTS
Seventeen of one hundred MCQs of the final summative exam-
inations covered the anatomy objectives of the flipped class-
rooms of the academic year (2018–2019) and those of the
traditional lectures of the academic year (2017–2018). Two
evaluators from the assessment unit in the College of Medicine
at Qassim University classified these questions according to
Bloom’s taxonomy levels of cognition (recall, understand,
apply, analyze, evaluate, create) (Adams, 2015). The “recall”
and “understand” classes were combined into one class called
“knowledge,” which was rated as a “low” level of cognition.
Eight anatomy MCQs were categorized in the knowledge class.
The other nine questions were classified as a “high” level of
cognition; five needed the students to “apply” and four to
“analyze” the items.
Concerning the ages of the students, the mean and ± SD in
the flipped classrooms group was 19.1 ± 0.4 and in the tradi-
tional classrooms was 19.1 ± 0.5. According to the indepen-
dent t test, the mean difference in their ages was nonsignificant,
0.317 (P-value = 0.752). The mean and ± SD of the results of
the final MSK module examinations was 68.1 ± 9.7 for the
flipped classrooms group, and 69.4 ± 11.6 for the traditional
group. The mean difference in the results of the final examina-
tions was nonsignificant, 0.599 (P-value = 0.550).
Analysis of Students’ Performance
Regarding the results of the anatomy questions at the levels
of knowledge, application, and analysis, the mean and ±SD
were 7.9 ± 1.5 (79.0 ± 15.0%), 3.1 ± 1.0 (77.5 ± 25.0%),
and 2.0 ± 0.9 (66.7 ± 30.0%) for the flipped classrooms and
were 7.3 ± 1.3 (73.0 ± 15.0%), 1.8 ± 1.0 (45.0 ± 25.0%),
and 1.2 ± 0.8 (40.0 ± 26.7%) for the traditional classrooms,
4
respectively. A significant mean difference was revealed con-
cerning the results of the questions at the three levels: 2.118
(P-value = 0.037), 6.873 (P-value = 0.001), and 4.902
(P-value = 0.001), respectively. The mean difference in the age
and final examination results of the students taught through
flipped and traditional classrooms using Cohen’s d test were
0.07 and 0.12, respectively. Concerning the students’ grades
on the anatomy questions, recorded during the assessment con-
ducted during both types of classrooms at the level of knowl-
edge, application, and analysis, they were 0.43, 1.41, and 1.01,
respectively using Cohen’s d test.
Analysis of Students’ and Staff Perceptions
Regarding students’ perceptions, 39 students (84.78%) com-
pleted the survey after the implementation of flipped classroom
(Figs. 1 and 2). The Cronbach’s alpha tests, used for all items
of the students’ and staff surveys, were 0.87 and 0.85, respec-
tively. The correlation coefficient was found to range from
0.188 to 0.658 and from 0.142 to 0.758 for the students and
staff surveys, respectively, indicating that the items in the sur-
vey were correlated well. Kaiser-Meyer-Olkin (KMO) measures
of sampling adequacy were 0.79 and 0.78, for the students and
staff surveys, respectively. Bartlett’s tests of sphericity were
0.001 and 0.46, for both students and staff surveys, respec-
tively, which was considered significant. Regarding the stu-
dents’ survey, two factors were extracted from the questions by
factor analysis, covering two main areas: “student preference”
and “evaluation of the flipped classroom experience.” The two
factors explained 82.85% of the cumulative variance: 65.6%
for factor 1 and 17.3% for factor 2. In addition, two factors
were extracted from the questions in the staff survey by factor
analysis, covering two main areas: “staff gain” and “attitude
with education methods.” The two factors explained 84.22%
of the cumulative variance: 63.3% for factor 1 and 21.0% for
factor 2.
Qualitative Analysis of Students Perceptions
The open-ended comments from the students’ questionnaire
were qualitatively analyzed and assigned into three themes:
Pre-class resources. Twenty-three percent (n = 8) of the
students reported satisfaction with the uploaded educational
materials before the class as they were clear, organized, and
appropriate for adequate understanding. They found the
recorded video tutorials very informative and convenient,
providing them with sufficient preparation for the class. The
students commented that the pre-class materials gave them the
opportunity to learn freely at their own pace. Six percent (n = 2)
of the students were worried about studying the materials
individually before the class and suggested that it would have
been more beneficial if they read and studied them in small
groups as a peer-sharing environment.
In-class activities. Thirty-one percent (n = 11) of the
students expressed their enthusiasm and interest in the in-
class interaction. They reported that the open discussion of
the problems clarified significant details and emphasized
important anatomical facts. They claimed that active
learning and peer-tutoring encouraged them to do more
critical thinking, reasoning, and problem solving. They
found the post-class quizzes very useful, as they provided an
opportunity for self-evaluation and ensured the consolidation
of their knowledge.
El Sadik and Al Abdulmonem
Figure 1.
Results of students’ survey regarding their perceptions about flipped classroom experience. Scores are based on a five-point Likert scale (1 = strongly disagree, 5 = strongly
agree) and expressed in means (±SD).

Benefits of flipped classroom. Forty percent (n = 14) of DISCUSSION

the students reported that the flipped classroom was a very
interesting learning style, which made them more committed
and attentive in the class and allowed them to be engaged in the
learning-teaching process. It gave them the ability to achieve
better understanding and analysis of the anatomy materials,
with more opportunity for in and out of class active learning.
They requested adoption of the flipped classroom in the
educational activities of the other disciplines.
Examples of students’ perceptions of the flipped class-
room experience are listed in Table 1 and in the Supporting
Information file.
Cohen’s d test revealed a small effect size in comparing the
mean difference of the age and final examination results of
the students, as well as their grades in anatomy questions at
the level of knowledge. This suggests that such differences
were trivial, even if statistically significant. On the contrary,
the students’ results in anatomy questions at both application
and analysis levels demonstrated a large effect size This finding
suggests the remarkable impact of flipping the anatomy class-
rooms on improving the students’ deeper levels of thinking
according to Bloom’s taxonomy. This finding was attributed

Figure 2.
Results of staff’s survey regarding their perceptions about flipped classroom experience. Scores are based on a five-point Likert scale (1 = strongly disagree, 5 = strongly
agree) and expressed in means (±SD).

Anatomical Sciences Education ## 20205

Table 1.
Themes and Examples of Supporting Students’ Quotes Regarding their Perceptions on Flipped Classroom Experience

Theme Example of Student’s Quote

Pre-class resources
• I found that uploading the educational materials, before the class, was accessible and
beneficial.
• I liked watching the educational videos and I could revise the uploaded materials any time
on my pace.
• I didn’t like to read the materials independently before the class as I may misunderstand
some points, so I prefer the traditional way.

In-class activities • I was very interested in practicing the flipped classroom activities as they helped me to
concentrate and to share these experiences with my colleagues.
• I found the in-class discussion and interactions very useful.
• I liked the post-class tests to discover my level of understanding.

Benefits of flipped classroom • Studying needed less effort and time for better understanding and concentration during the
class.
• Flipped classroom gave me the chance for better achievement.
• I prefer flipping of the class in all other disciplines.

to the effect of flipped classroom on students’ learning pro-
cess. It reflected higher levels of understanding, application,
and analysis, which were significantly higher in flipped than
in the traditional teaching group. Students’ performance was
enhanced through integration between self-studying of the pre-
class uploaded materials and open discussion during the class.
This outcome could be explained by the articulation between
the cognitive domain, in the pre-class work, and psychomotor
and attitude domains practiced in the class. The findings of the
present study were consistent with the results of many authors
who recorded that flipped classroom had great impact on the
students’ performance (Handelsman et al., 2004; Tune et al.,
2013; Jensen et al., 2015; Stockwell et al., 2015; Street et al.,
2015; Bakr et al., 2016a; Koo et al., 2016; Ryan and Reid, 2016;
Gopalan and Klann, 2017; Dooley et al., 2018; Megaw and
Zimanyi, 2019). Formative in-class assessments provided the
students an immediate self-evaluation of their knowledge gaps
(McLaughlin et al., 2014; Park and Howell, 2015). However,
Chutinan et al. (2018) detected that flipped classroom pro-
moted students’ performance in a short-term evaluation, but
did not affect their performance at the final summative exam-
ination. They suggested redesign of the new pedagogic strat-
egy to be carefully implemented. Other researchers found no
difference in students’ performance in the flipped classroom
study compared to the traditional lectures (Wong et al., 2014;
Fautch, 2015; Moraros et al., 2015; Whillier and Lystad, 2015;
Ojennus, 2016). Another study performed on flipping gross
anatomy classrooms detected that the flipped classroom was
more beneficial for lower performing students’ knowledge
gaining and relocation than for higher performing students
(Day, 2018). Morton and Golbert-Getz (2017) attributed this
difference to the Bloom’s level of cognition. An assessment
focusing only on the level of recall of information would mostly
show no difference in performance between flipped and tradi-
tional classrooms, which was in agreement with the results of
the present work. On the contrary, the flipped classroom was
designed to increase the level of students’ application and anal-
ysis which explained the improvement of the results of these
questions in the flipped classroom group over the traditional
group. Thus, this study emphasized the ability of the flipped
classroom to increase the students’ efficiency to solve problems
at higher levels of Bloom’s taxonomy. This finding was consis-
tent with Shi et al. (2020) who reported that the flipped class-
room would improve students’ cognitive learning outcomes,
especially with a collaborative environment that enhanced the
pedagogic approaches.
The current work demonstrates multiple benefits of the
flipped classroom for students, including the independent
learning experience gained by digitalization of educational
materials and the availability of multiple online educational
resources. These materials represent a fast and economical
way to enhance blended learning and provide an integration
between teaching and technology which is in agreement with
Belfli et al. (2015), Bakr et al. (2016a, b), Dooley et al. (2018),
Shang and Liu (2018), and Hettiarachchi (2019). The students
who participated in the perception survey were satisfied with
the prerecorded video materials, as this pre-class activity pro-
vided them multiple chances to review the contents and restudy
them, as was called “homework” before the flipped classroom
(Herreid and Schiller, 2013). These materials allowed the stu-
dents to learn calmly at their own pace without physical setting
constrains and made the full use of the numerous components
of the topics. Topping (2014) suggested that the anatomy vid-
eos were a very useful computer-aided instruction that might
provide a compensation to the reduction of gross anatomy
courses. However, some students complained of their fear of
working independently and of the heavy pre-class workload,
which were also reported by Missildine et al. (2013), Wong et al.
(2014), and Kugler et al. (2019). This problem could be solved
by reassuring and encouraging them to raise their accountabil-
ity and sense of responsibility in the students’ awareness ses-
sions. In addition, recommendations should be highlighted for
educators about the key challenges of the pre-class resources
such as the students’ study load, the length of the videos, the
dedicated teachers for construction of the videos, and the time
required for teachers to prepare them and required for the stu-
dents to study them (Al-Zahrani, 2015; Bakr et al., 2016b;
Al-Samarraie et al., 2019). The relatively high level of internal
consistency of students and staff survey were based upon the
Cronbach’s alpha test. All correlation coefficients, utilizing the
Kendall’s tau B test on these surveys were positive, reflecting
their validity and demonstrating that the items in the surveys

6 El Sadik and Al Abdulmonem

were correlated well. Determination of the appropriateness of
the data obtained from student and staff surveys was needed
to proceed with factor analysis. It was based upon the cur-
rent results of KMO measure of sampling adequacy (more
than 0.6) and the significance of Bartlett’s test. These tests
indicated that the sample size was large enough to assess the
factor structure and the strong relationship among items of
the surveys. One of the points highlighted in the survey was
the benefit of the flipped classroom in providing the instruc-
tor a sufficient time for face-to-face interaction and in creat-
ing an optimal learning environment for student engagement
after online preparation. Instructors reported that the flipped
classroom could increase their teaching skills and experiences
as well as students’ creativity and interaction. This blending
of traditional face-to-face in-class and pre-class online activi-
ties allowed an effective student-centered educational process.
The flipped classroom also provided a self-directed learning
experience that promoted long-life learning skills (Hagemeier
and Mason, 2011; Belfli et al., 2015; Park and Howell, 2015).
Another advantage of the flipped classroom was the observed
in the positive attitude of students toward a variety of educa-
tional activities. This finding emphasized that the shift from
passive traditional teaching to more active flipped learning
promotes students’ engagement, performance, and achieve-
ment (Jensen et al., 2015; Park and Kim, 2016; Ramnanan and
Pound, 2017; Al-Samarraie et al., 2019; Megaw and Zimanyi,
2019). The students revealed their high satisfaction toward the
flipped classroom modality, as they were interested in active
learning, class interaction, critical thinking, and problem solv-
ing allowed by this educational strategy, which was in agree-
ment with Pierce and Fox (2012), Critz and Knight (2013),
McLaughlin et al. (2014), Hanson (2016), McLean and
Attardi (2018), and Strelan et al. (2020). Al-Zahrani (2015)
detected that flipped classroom significantly promoted stu-
dents’ creativity, especially with respect to fluency, flexibility,
and novelty. However, regular monitoring of the learning goals
and the action plan of students’ achievements should be kept
in consideration (Koo et al., 2016). The flipped classroom may
help overcome the problems faced in the traditional classes
of student hesitation lack of self-confidence, and little peer
and teacher interaction. Entezari and Javdan (2016) reported
that these negative behaviors affected the results of summa-
tive assessments, which could be one of the major causes of
dropping out from the college. On the contrary, students who
might lack self-confidence or prefer traditional education
deserved specific attention as they needed further support to
be familiar with the flipped class. Surprisingly, some of the
anatomy staff postulated, in their perception survey, that stu-
dents would not prefer the flipped classroom over the tradi-
tional teaching and were uncertain about students’ response
to the flipped classroom, which was contrary to the results
of students’ satisfaction survey. These teachers claimed that
although traditional lectures could be boring, some additional
strategies could be utilized to promote students’ engagement
and active participation as suggested by Pickering and Roberts
(2018). Jambi et al. (2015) detected that staff development is
a key challenge when designing a new educational modality.
To overcome this challenge, further awareness sessions were
scheduled for the anatomy staff, coping with their needs to
upgrade their educational strategies and motivate them con-
tinuously, as recommended by Jambi et al. (2015). It is cru-
cial to note that the flipped classroom might not fit for every
teacher, course, or student (Strayer, 2012; Hussey et al., 2014).
For example, employed students, especially with a full-time
Anatomical Sciences Education ## 20207
work, should have special considerations when choosing to
educate them with flipped classroom (Christopher, 2018). In
addition, the role of the educator is to select the topics that
are appropriate to be read and studied by the student individ-
ually in the pre-class activities, and the ones that remain to
be discussed in-class with the teacher. The present study rein-
forced the point that more passive and simple activities could
be moved prior to the class, while difficult concepts could be
delivered and practiced in tutorials during classroom activities
with more active student engagement, which is the basis of the
flipped classroom educational strategy.
Limitation of the Study
One of the limitations of the study was the low number of the
anatomy staff participating in the survey, as well as the num-
ber of students expressing their reflections in their survey.
Accordingly, regression analysis for the relationship between
the weighted factor scores of the students and their examination
scores could not be applied due to incomplete contributions
from the students in the surveys. Another limitation was the low
number of questions in the surveys that involved the principal
component analysis. Finally, staff resistance to the new teach-
ing method of the flipped classroom and their preference for
the traditional lectures was considered a limitation of the study,
which could be overcome by multiple awareness sessions about
the potential benefits and outcomes of a flipped classroom.
CONCLUSIONS
This study adds to the literature that investigates the impact of
a flipped classroom. It emphasizes its influence on Qassim med-
ical students’ performance, specifically in the gross anatomy
classrooms. In order to graduate efficient health-care providers,
advanced assessment of performance should be delivered. This
type of assessment would ensure skills in answering different
cognitive test levels, which could be provided by the flipped class-
room modality. The findings of the present study clarify the ben-
efits of the flipped classroom, particularly when the assessment
requires application or analysis. The surveys revealed that most
of the students were interested in the pre-class activities, which
facilitated their engagement and concentration during the class.
However, further studies are required to determine the best prac-
tices of flipped classroom that could meet the learning needs of
the students and provide them a pleasurable learning experience.
ACKNOWLEDGMENT
The authors would like to acknowledge College of Medicine,
Qassim University for the generous facilitation of the required
learning resources. The authors declare that there is no conflict
of interests.
NOTES TO CONTRIBUTORS
ABIR EL SADIK, M.B.B.Ch. M.Sc., M.D., is a professor of
anatomy and embryology in the Department of Anatomy and
Histology at College of Medicine, Qassim University, Qassim,
Kingdom of Saudi Arabia and in the Department of Anatomy
and Embryology at College of Medicine, Cairo University,
Cairo, Egypt. She is a fellow in Ain Shams University Middle
East North Africa-FAIMER Regional Institute (ASU-MENA-
FRI). She teaches anatomy and embryology to basic years
medical and paramedical students and her research interest is
in anatomy education and stem cells.
WALEED AL ABDULMONEM, Ph.D., is an assistant
professor of molecular medicine and the Head of Pathology
Department at College of Medicine, Qassim University, Qassim,
Kingdom of Saudi Arabia. He teaches immunology to the basic
years medical and paramedical students and his research inter-
est is medical education and genetics.
LITERATURE CITED
Abdi H. 2007. The Kendall rank correlation coefficient. In: Salkin NJ (Editor).
Encyclopedia of Measurement and Statistics. 1st Ed. Thousand Oaks, CA: SAGE
Publications, Inc. p 508–510.
Abeysekera L, Dawson P. 2015. Motivation and cognitive load in the flipped
classroom: Definition, rationale and a call for research. High Educ Res Dev
34:1–14.
Adams NE. 2015. Bloom’s taxonomy of cognitive learning objectives. J Med Lib
Assoc 103:152–153.
Alamro AS. 2019. Analysing undergraduate medical curricula: Experience from a
Saudi Medical College. Majmaah J Health Sci 7:20–33.
Alamro AS, Schofield S. 2012. Supporting traditional PBL with online discussion
forums: A study from Qassim Medical School. Med Teach 34:S20–S24.
Alrebish SA, Taha MH, Ahmed MH, Abdalla ME. 2020. Commitment towards
a better future for medical education in Saudi Arabia: The efforts of the College
of Medicine at Qassim University to become socially accountable. Med Educ
Online 25:1710328.
Al-Samarraie H, Shamsuddin A, Alzahrani AI. 2019. A flipped classroom model
in higher education: A review of the evidence across disciplines. Educ Technol
Res Dev 2019:1–35.
Al-Zahrani AM. 2015. From passive to active: The impact of the flipped class-
room through social learning platforms on higher education students’ creative
thinking. Br J Educ Technol 46:1133–1148.
Anderson LW, Krathwohl DR, Airasian PW, Cruikshank KA, Mayer RE, Pintrich
PR, Raths J, Wittrock MC. 2001. A Taxonomy for learning, Teaching and
Assessing: A Revision of Bloom’s Taxonomy of Educational Objectives. 1st Ed.
New York, NY: Longman. 336 p.
Andrews TM, Leonard MJ, Colgrove CA, Kalinowski ST. 2011. Active learn-
ing not associated with student learning in a random sample of college biology
courses. CBE Life Sci Educ 10:394–405.
Asef-Vaziri A. 2015. The flipped classroom of operations management: A not-
for-cost-reduction platform. Decis Sci J Innovat Educ 13:71–89.
Baeten M, Kyndt E, Struyven K, Dochy F. 2010. Using student-centred learning
environments to stimulate deep approaches to learning: Factors encouraging or
discouraging their effectiveness. Educ Res Rev 5:243–260.
Bakr MM, Massey WL, Massa HM. 2016a. Flipping a dental anatomy course: A
retrospective study over four years. Educ Res Int 2016:7097398.
Bakr MM, Massey WL, Massa HM. 2016b. Digital cadavers: Online 2D learning
resources enhance student learning in practical head and neck anatomy within
dental programs. Educ Res Int 2016:8506251.
Bates JE, Almekdash H, Gilchrest-Dunnam MJ. 2017. The flipped classroom: A
brief, brief history. In: Santos Green L, Banas J, Perkins R (Editors). The Flipped
College Classroom: Conceptualized and Re-Conceptualized. 1st Ed. Cham,
Switzerland: Springer International Publishing. p 3–10.
Belfli LM, Bartolotta RJ, Giambrone AE, Davi C, Min RJ. 2015. Flipping the
introductory clerkship in radiology: Impact on medical student performance and
perceptions. Acad Radiol 22:794–801.
Bergman EM, van der Vleuten CP, Scherpbier AJ. 2011. Why don’t they know
enough about anatomy? A narrative review. Med Teach 33:403–409.
Betihavas V, Bridgman H, Kornhaber R, Cross M. 2016. The evidence for ‘flip-
ping out’: A systematic review of the flipped classroom in nursing education.
Nurse Educ Today 38:15–21.
Boevé AJ, Meijer RR, Bosker RJ, Vugteveen J, Hoekstra R, Albers CJ. 2017.
Implementing the flipped classroom: An exploration of study behaviour and stu-
dent performance. High Educ 74:1015–1032.
Bouwmeester RA, de Kleijn RA, ten Cate OT, van Rijen HV, Westerveld HE.
2016. How do medical students prepare for flipped classrooms? Med Sci Educ
26:53–60.
Cagande JL, Jugar RR. 2018. The flipped classroom and college physics students’
motivation and understanding of kinematics graphs. Issues Educ Res 28:288–307.
Castedo R, López LM, Chiquito M, Navarro J, Cabrera JD, Ortega MF. 2019.
Flipped classroom—Comparative case study in engineering higher education.
Comput Appl Eng Educ 27:206–216.
Chan LL, Idris N. 2017. Validity and reliability of the instrument using explor-
atory factor analysis and Cronbach’s alpha. Int J Acad Res Bus Soc Sci 7:400–410.
Chen F, Lui AM, Martinelli SM. 2017. A systematic review of the effectiveness of
flipped classrooms in medical education. Med Educ 51:585–597.
8
Cheng X, Lee KK, Chang EY, Yang X. 2017. The “flipped classroom” approach:
Stimulating positive learning attitudes and improving mastery of histology
among medical students. Anat Sci Educ 10:317–327.
Christopher SV. 2018. Students’ perceptions of a flipped classroom approach to
paramedic theory. Br Paramed J 2:1–9.
Chutinan S, Riedy CA, Park SE. 2018. Student performance in a flipped class-
room dental anatomy course. Eur J Dent Educ 22:e343–e349.
Cohen J. 1992. A power primer. Psychol Bull 112:155–159.
Cook DA, Beckman TJ. 2006. Current concepts in validity and reliability for psy-
chometric instruments: Theory and application. Am J Med 166:e7–e16.
Critz CM, Knight D. 2013. Using the flipped classroom in graduate nursing edu-
cation. Nurse Educ 38:210–213.
Dangerfield P, Bradley P, Gibbs T. 2000. Learning gross anatomy in a clinical
skills course. Clin Anat 13:444–447.
Day LJ. 2018. A gross anatomy flipped classroom effects performance, reten-
tion, and higher-level thinking in lower performing students. Anat Sci Educ
11:565–574.
Della Ratta CB. 2015. Flipping the classroom with team-based learning in under-
graduate nursing education. Nurse Educ 40:71–74.
Deslaureiers L, Schelew E, Wieman C. 2011. Improved learning in a large-
enrollment physics class. Science 332:862–864.
Ding C, Li S, Chen B. 2019. Effectiveness of flipped classroom combined with
team-, case-, lecture- and evidence-based learning on ophthalmology teaching for
eight-year program students. BMC Med Educ 19:419.
Dooley LM, Frankland S, Boller E, Tudor E. 2018. Implementing the flipped
classroom in a veterinary pre-clinical science course: Student engagement, perfor-
mance, and satisfaction. J Vet Med Educ 45:195–203.
Entezari M, Javdan M. 2016. Active learning and flipped classroom, hand in
hand approach to improve students learning in human anatomy and physiology.
Int J High Educ 5:222–231.
Estai M, Bunt S. 2016. Best teaching practices in anatomy education: A critical
review. Ann Anat 208:151–157.
Fasel JH, Morel P, Gailloud P. 2005. A survival strategy for anatomy. Lancet
365:754.
Fautch JM. 2015. The flipped classroom for teaching organic chemistry in small
classes: Is it effective? Chem Educ Res Pract 16:179–186.
Ferrer-Torregrosa J, Jiménez-Rodríguez MÁ, Torralba-Estelles J, Garzón-Farinós
F, Pérez-Bermejo M, Fernández-Ehrling N. 2016. Distance learning ECTS and
flipped classroom in the anatomy learning: Comparative study of the use of aug-
mented reality, video and notes. BMC Med Educ 16:230.
Fleagle TR, Borcherding NC, Harris J, Hoffmann DS. 2018. Application of
flipped classroom pedagogy to the human gross anatomy laboratory: Student
preferences and learning outcomes. Anat Sci Educ 11:385–396.
Freeman S, Eddy SL, McDonough M, Smith MK, Okoroafor N, Jordt H,
Wenderoth MP. 2014. Active learning increases student performance in science,
engineering, and mathematics. Proc Natl Acad Sci U S A 111:8410–8415.
Gopalan C, Klann MC. 2017. The effect of flipped teaching combined with modified
team-based learning on student performance in physiology. Adv Physiol Educ 41:363–367.
Grypp L, Luebeck J. 2015. Rotating solids and flipping instruction. Math Teach
109:186–193.
Hagemeier NE, Mason HL. 2011. Student pharmacists’ perceptions of testing
and study strategies. Am J Pharm Educ 75:35.
Han E, Klein KC. 2019. Pre-class learning methods for flipped classrooms. Am J
Pharm Educ 83:6922.
Handelsman J, Ebert-May D, Beichner R, Bruns P, Chang A, DeHaan R, Gentile J,
Lauffer S, Stewart J, Tilghman SM, Wood WB. 2004. Scientific teaching. Science
304:521–522.
Hanson J. 2016. Surveying the experiences and perceptions of undergradu-
ate nursing students of a flipped classroom approach to increase understand-
ing of drug science and its application to clinical practice. Nurse Educ Pract
16:79–85.
Heitz C, Prusakowski M, Willis G, Franck C. 2015. Does the concept of the
“flipped classroom” extend to the emergency medicine clinical clerkship? West J
Emerg Med 16:851–855.
Herreid CF, Schiller NA. 2013. Case studies and the flipped classroom. J Col Sci
Teach 42:62–66.
Hettiarachchi E. 2019. Analyzing the impact of introducing active learning in a
blended educational environment. Int J Learn Teach 65:285–291.
Hew KF, Lo CK. 2018. Flipped classroom improves student learning in health
professions education: A meta-analysis. BMC Med Educ 18:38.
Hurtubise L, Hall E, Sheridan L, Han H. 2015. The flipped classroom in medi-
cal education: Engaging students to build competency. J Med Educ Curric Dev
2:35–43.
Hussey HD, Fleck BK, Richmond AS. 2014. Promoting active learning through a
flipped course design. In: Keengwe J, Onchwari G, Oigara J (Editors). Promoting
Active Learning Through the Flipped Classroom Model. 1st Ed. Hershey PA:
Information Science Reference. p 23–46.
Hwang GJ, Lai CL, Wang SY. 2015. Seamless flipped learning: A mobile technol-
ogy-enhanced flipped classroom with effective learning strategies. J Comp Educ
2:449–473.
El Sadik and Al Abdulmonem
Jambi S, Khalifah AM, Fadel HT. 2015. Shifting from traditional lecturing to
interactive learning in Saudi dental schools: How important is staff development?
J Taibah Univ Med Sci 10:45–49.
Jensen JL, Kummer TA, d M Godoy PD. 2015. Improvements from a flipped
classroom may simply be the fruits of active learning. CBE Life Sci Educ 14:ar5.
Kellesarian SV. 2018. Flipping the dental anatomy classroom. Dent J 6:23.
Kemeir M. 2012. Attitudes and views of medical students toward anatomy learnt
in the preclinical phase at King Khalid University. J Family Community Med
19:190–193.
Khan MM. 2007. Assessment of anatomy curriculum for future clinicians
at College of Medicine, King Saud University, Saudi Arabia. Pak J Med Sci
23:625–629.
Kim MK, Kim SM, Khera O, Getman J. 2014. The experience of three flipped
classrooms in an urban university: An exploration of design principles. Internet
High Educ 22:37–50.
Koo CL, Demps EL, Farris C, Bowman JD, Panahi L, Boyle P. 2016. Instructional
design and assessment. Impact of flipped classroom design on student perfor-
mance and perceptions in a pharmacotherapy course. Am J Pharm Educ 80:33.
Kraut AS, Rodney O, Caretta-Weyer H, Jordan J, Manthey D, Stephen JW, Yarris
LM, Johnson S, Kornegay J. 2019. The flipped classroom: A critical appraisal.
West J Emerg Med 20:527–536.
Kugler AJ, Gogineni HP, Garavalia LS. 2019. Learning outcomes and student
preferences with flipped vs lecture/case teaching model in a block curriculum.
Am J Pharm Educ 83:7044.
Lew EK. 2016. Creating a contemporary clerkship curriculum: The flipped class-
room model in emergency medicine. Int J Emerg Med 9:25.
Lo CK, Hew KF. 2019. The impact of flipped classrooms on student achievement
in engineering education: A meta-analysis of 10 years of research. Res J Eng Educ
108:523–554.
Mason GS, Shuman TR, Cook KE. 2013. Comparing the effectiveness of an
inverted classroom to a traditional classroom in an upper-division engineering
course. IEEE Trans Educ 56:430–435.
Mazur E. 2009. Farewell, lecture? Science 323:50–51.
McCutcheon K, Lohan M, Traynor M, Martin D. 2015. A systematic review eval-
uating the impact of online or blended learning vs. face-to-face learning of clini-
cal skills in undergraduate nurse education. J Adv Nurs 71:255–270.
McLaughlin JE, Roth MT, Glatt DM, Gharkholonarehe N, Davidson CA, Griffin
LM, Esserman DA, Mumper RJ. 2014. The flipped classroom: A course rede-
sign to foster learning and engagement in a health professions school. Acad Med
89:236–243.
McLean S, Attardi SM. 2018. Sage or guide? Student perceptions of the role of the in-
structor in a flipped classroom. Active Learn High Educ 2018:1469787418793725.
Megaw PL, Zimanyi MA. 2019. Redesigning first year anatomy and physi-
ology subjects for allied health students: Introducing active learning experi-
ences for physiology in a first semester subject. Int J Innovat Sci Math Educ
27:26–35.
Missildine K, Fountain R, Summers L, Gosselin K. 2013. Flipping the classroom
to improve student performance and satisfaction. J Nurs Educ 52:597–599.
Moffett J. 2015. Twelve tips for “flipping” the classroom. Med Teach 37:331–336.
Moffett J, Mill AC. 2014. Evaluation of the flipped classroom approach in a vet-
erinary professional skills course. Adv Med Educ Pract 5:415–425.
Moraros J, Islam A, Yu S, Banow R, Schindelka B. 2015. Flipping for success:
Evaluating the effectiveness of a novel teaching approach in a graduate level set-
ting. BMC Med Educ 15:27.
Moravec M, Williams A, Aguilar-Roca N, O’Dowd DK. 2010. Learn before lec-
ture: A strategy that improves learning outcomes in a large introductory biology
class. CBE Life Sci Educ 9:473–481.
Morton DA, Colbert-Getz JM. 2017. Measuring the impact of the flipped anat-
omy classroom: The importance of categorizing an assessment by Bloom’s taxon-
omy. Anat Sci Educ 10:170–175.
O’Connor EE, Fried J, McNulty N, Shah P, Hogg JP, Lewis P, Zeffiro T, Agarwal
V, Reddy S. 2016. Flipping radiology education right side up. Acad Radiol
23:810–822.
O’Flaherty J, Phillips C. 2015. The use of flipped classrooms in higher education:
A scoping review. Internet High Educ 25:85–95.
Ojennus DD. 2016. Assessment of learning gains in a flipped biochemistry class-
room. Biochem Mol Biol Educ 44:20–27.
Omar H. 2009. The state of human anatomy teaching in the medical schools of
Gulf Cooperation Council Countries. Sultan Qaboos Univ Med J 9:24–31.
Park SE, Howell TH. 2015. Implementation of a flipped classroom educational
model in a predoctoral dental course. J Dent Educ 79:563–570.
Park W, Kim H. 2016. A case study of flipped classroom applied in the classroom:
Focusing on academic and nonacademic experiences, and classroom engagement
of university students. J Learn Curric Instr 16:525–546.
Pickering JD, Roberts DJ. 2018. Flipped classroom or an active lecture? Clin
Anat 31:118–121.
Pierce R, Fox J. 2012. Vodcasts and active-learning exercises in a “flipped class-
room” model of a renal pharmacotherapy module. Am J Pharm Educ 76:196.
Prasad Kuppili VR, Venkatachelam R. 2017. Flipped classroom as a large group
teaching in anatomy. IOSR J Dent Med Sci 16:19–23.
Anatomical Sciences Education ## 20209
Priyaadharshini M, Sundaram BV. 2018. Evaluation of higher-order thinking
skills using learning style in an undergraduate engineering in flipped classroom.
Comput Appl Eng Educ 26:2237–2254.
Prober CG, Heath C. 2012. Lecture halls without lectures–A proposal for medi-
cal education. N Engl J Med 366:1657–1659.
Prober CG, Khan S. 2013. Medical education reimagined: A call to action. Acad
Med 88:1407–1410.
Ramnanan CJ, Pound LD. 2017. Advances in medical education and practice:
Student perceptions of the flipped classroom. Adv Med Educ Pract 8:63–73.
Roe Y, Rowe M, Odegaard NB, Sylliaas H, Dahl-Michelsen T. 2019. Learning
with technology in physiotherapy education: Design, implementation and evalu-
ation of a flipped classroom teaching approach. BMC Med Educ 19:291.
Roehl A, Reddy SL, Shannon GJ. 2013. The flipped classroom: An opportunity
to engage millennial students through active learning strategies. J Fam Consum
Sci 105:44–49.
Ryan MD, Reid SA. 2016. Impact of the flipped classroom on student perfor-
mance and retention: A parallel controlled study in general chemistry. J Chem
Educ 93:13–23.
Saqr M, Alamro A. 2019. The role of social network analysis as a learning analyt-
ics tool in online problem-based learning. BMC Med Educ 19:160.
Shang F, Liu CY. 2018. Blended learning in medical physiology improves nursing
students’ study efficiency. Adv Physiol Educ 42:711–717.
Sharma N, Lau CS, Doherty I, Harbutt D. 2015. How we flipped the medical
classroom. Med Teach 37:327–330.
Shi Y, Ma Y, MacLeod J, Yang HH. 2020. College students’ cognitive learning
outcomes in flipped classroom instruction: A meta-analysis of the empirical liter-
ature. J Comput Educ 7:79–103.
Shin J, Brock TP. 2017. Content delivery models influence class preparation,
study habits, and preferences. Pharm Educ 17:341–349.
Stockwell BR, Stockwell MS, Cennamo M, Jiang E. 2015. Blending learning im-
proves science education. Cell 162:933–936.
Strayer JF. 2012. How learning in an inverted classroom influences cooperation,
innovation and task orientation. Learn Environ Res 15:171–193.
Street SE, Gilliland KO, McNeil C, Royal K. 2015. The flipped classroom im-
proved medical student performance and satisfaction in a pre-clinical physiology
course. Med Sci Educ 25:35–43.
Strelan P, Osborn A, Palmer E. 2020. The flipped classroom: A meta-analysis of
effects on student performance across disciplines and education levels. Educ Res
Rev 30:100314.
Sun Z, Xie K. 2020. How do students prepare in the pre-class setting of a flipped
undergraduate math course? A latent profile analysis of learning behavior and
the impact of achievement goals. Internet High Educ 46:100731.
Sun Z, Xie K, Anderman LH. 2018. The role of self-regulated learning in students’
success in flipped undergraduate math courses. Internet High Educ 36:41–53.
Taber KS. 2018. The use of Cronbach’s alpha when developing and reporting
research instruments in science education. Res Sci Educ 48:1273–1296.
Taylor AT, Olofson EL, Novak WR. 2017. Enhancing student retention of prereq-
uisite knowledge through pre-class activities and inclass reinforcement. Biochem
Mol Biol Educ 45:97–104.
Topping DB. 2014. Gross anatomy videos: Student satisfaction, usage,
and effect on student performance in a condensed curriculum. Anat Sci Educ
7:273–279.
Tune JD, Sturek M, Basile DP. 2013. Flipped classroom model improves gradu-
ate student performance in cardiovascular, respiratory, and renal physiology. Adv
Physiol Educ 37:316–320.
Veeramani R, Madhugiri VS, Chand P. 2015. Perception of MBBS students
to “flipped class room” approach in neuroanatomy module. Anat Cell Biol
48:138–143.
Waterston SW, Stewart IJ. 2005. Survey of clinicians’ attitudes to the anatomical
teaching and knowledge of medical students. Clin Anat 18:380–384.
Watson TD. 2015. Snack cake ‘dissection’: A flipped classroom exercise to en-
gage undergraduates with basic neuroanatomy. J Undergrad Neurosci Educ
14:A8–A12.
Whillier S, Lystad RP. 2015. No differences in grades or level of satisfaction in a
flipped classroom for neuroanatomy. J Chiropract Educ 29:127–133.
Williams C, Perlis S, Gaughan J, Phadtare S. 2018. Creation and implementation
of a flipped jigsaw activity to stimulate interest in biochemistry among medical
students. Biochem Mol Biol Educ 46:343–353.
Wong T, Ip EJ, Lopes I, Rajagopalan V. 2014. Pharmacy students’ performance
and perceptions in a flipped teaching pilot on cardiac arrhythmias. Am J Pharm
Educ 78:185.
Woodruff AE, Jensen M, Loeffler W, Avery L. 2014. Advanced screencasting with
embedded assessments in pathophysiology and therapeutics course modules. Am
J Pharm Educ 78:128.
Yaqinuddin A, Ikram MF, Zafar M, Sharaf Eldin N, Mazhar MA, Qazi S, Shaikh
AA, Obeidat A, Al-Kattan K, Ganguly P. 2016. The integrated clinical anatomy
program at Alfaisal University: An innovative model of teaching clinically applied
functional anatomy in a hybrid curriculum. Adv Physiol Educ 40:56–63.
Zheng B, Zhang Y. 2020. Self-regulated learning: The effect on medical student
learning outcomes in a flipped classroom environment. BMC Med Educ 20:100.